MEDICAL-SURGICAL NURSING 1

3rd Year | 1st Semester

Lecturer: Jim Rashid Hayudini, RN, MN

CARE OF CLIENT WITH RESPIRATORY DISORDERS • The upper airway of the respiratory system is made up of the
Respiration nose, mouth, pharynx, larynx, and trachea. The upper airway's
• The mechanism that controls respiration is primarily the medulla function is to warm, humidify, and filter the air we breathe.
oblongata. Lower airway
Respiration is the act of breathing that involves: • The lower airway of the respiratory system includes the bronchi,
1. Inspiration – inhalation; breathing in of air. bronchioles, alveolar ducts, and alveoli. The key function of the
2. Expiration – exhalation; breathing out of air. lower airway is gas exchange, and alveoli are the functional units
Medulla Oblongata for gas exchange.
• The medulla sends signals to the muscles that initiate inspiration
and expiration and controls non respiratory air movement
reflexes, like coughing and sneezing.
Respiratory control centers:
✓ The medulla which sends signals to the muscles involved in
breathing.
✓ The pons which controls the rate of breathing.
There are two regions in the medulla that control respiration:
1. The ventral respiratory group stimulates expiratory movements.
The ventral respiratory group controls voluntary forced exhalation
and acts to increase the force of inspiration.
2. The dorsal respiratory group stimulates inspiratory
movements.
(Nucleus Tractus Solitarius) controls mostly inspiratory
movements and their timing.
• Ventilatory rate (minute volume) – tightly controlled and
determined primarily by blood levels of carbon dioxide as
determined by metabolic rate.
Pleura
Chemoreceptors
• We have pleura that surround and cushion each of the lungs. The
• These are receptors in the medulla and in the aortic and carotid
space between the two layers of the pleura is known as the
bodies of the blood vessels that detect changes in blood pH
pleural cavity. When we cover disorders of the respiratory system
and signal the medulla to correct those changes.
later in this series, you will notice that some disorders cause a
• The apneustic (stimulating) and pnuemotaxic (limiting)
buildup of air, blood, or fluid in that pleural cavity, which
centers of the pons work together to control rate of breathing.
compresses the lungs and puts the lungs at risk for collapse.
Blood Flow in the Lungs
1. Deoxygenated blood from the body goes to the right atrium, then the right
ventricle, then to the lungs.
2. In the lungs, the alveoli absorb carbon dioxide FROM the capillaries,
which allows us to breathe out carbon dioxide.
3. Alveoli diffuse oxygen (that we've breathed in) INTO the capillaries, which
oxygenates our blood.
4. The oxygenated blood returns to the left atrium.

Upper Respiratory Tract Ventilation – flow of air in and out of the alveoli. If a patient were to have a
- filters, moistens, warms condition like asthma, that results in bronchoconstriction, which would impair
Lower Respiratory Tract their ventilation.
- enables exchange of gases between blood and air to regulate Diffusion – the exchange of oxygen and carbon dioxide between the alveoli
serum PO2, PCO2 and pH. and the red blood cells in the bloodstream.
During Inspiration If a patient were to have a condition like pulmonary fibrosis, which causes
✓ Respiratory muscles contract. scarring and thickening of the lung tissue, that makes diffusion less effective.
✓ Thoracic cavity increases. Perfusion – the exchange of oxygen and carbon dioxide between red blood
✓ Diaphragm contracts and moves downward in the thorax. cells and the body's tissues.
✓ Intra thoracic pressure decreases. If a patient had a condition such as peripheral arterial disease, which results
✓ Air moves in of the respiratory tract. in impaired blood flow to extremities, it affects perfusion to the cells in the
During expiration lower extremities. Peripheral arterial disease is covered in the cardiovascular
✓ Respiratory muscles relax. section.
✓ Thoracic cavity decreases.
✓ Stretched elastic lung tissue recoil. Cellular Respiration – a set of metabolic reactions and processes that take
✓ Intra thoracic pressure increases. place in the cells of organisms to convert chemical energy from oxygen
✓ Air moves out of the respiratory tract. molecules or nutrients into adenosine triphosphate, and then release waste
products.
The Respiratory system
• The key function of the respiratory system is gas exchange. Problems Associated with Respiration
Signs and Symptoms of HYPOXIA
• The respiratory system provides oxygen to the body's cells and
✓ Decreased energy
removes carbon dioxide from the body.
✓ Restlessness
Respiratory System Components
✓ Rapid, shallow breathing
The respiratory system comprises an upper airway and lower airway.
✓ Rapid heart rate
✓ Sitting to breathe
Upper Airway
OUTLINE BY: CHARIS JILL A. DAUTIL
MEDICAL-SURGICAL NURSING 1
3rd Year | 1st Semester
Lecturer: Jim Rashid Hayudini, RN, MN

✓ Nasal flaring 2. Inspiratory Reserve Volume – extra volume of air that can be
✓ Use of accessory muscles to breathe inspired over & beyond the normal tidal volume, about 3000ml
✓ Increased BP 3. Expiratory Reserve Volume – amount of air that can still be
✓ Sleepiness, confusion, stupor, coma expired by forceful expiration after the end of a normal tidal
✓ Cyanosis of skin, lips, nail bed expiration, about 1100ml.
Note: 4. Residual Volume – volume of air still remaining in the lungs after
• Hypoxia is a condition in which the body or a region of the body the most forceful expiration, averages about 1200ml.
is deprived of adequate oxygen supply at the tissue level. Pulmonary "Capacities:"
• Hypoxemia refers to the low level of oxygen in blood. 1. Inspiratory Capacity – equals TV + IRV, about 3500ml.
• Hypoxemia can cause hypoxia. • amount of air that a person can breathe beginning at the normal
Common Diagnostic Tests expiratory level & distending his lungs to maximum amount.
Arterial Blood Gases (ABG) 2. Functional Residual Capacity – equals ERV + RV.
• Arterial blood is extracted to assess oxygenation, ventilation and • about amount of air remaining in the lungs at the end of normal
acid – base balance in blood. expiration, about 2300ml.
• Measures the PaO2, PaCO2, SaO2 and pH of blood. 3. Vital Capacity – equals IRV + TV + ERV or 1C + ERV, about
An ABG measures the following: 4600ml.
✓ pH – the amount of free hydrogen ions in the arterial blood (H+). • maximum amount of air that a person can expel from the lungs
✓ PaO2 – the partial pressure of oxygen. after filling the lungs to their maximum extent & expiring to the
✓ PaCO2 – the partial pressure of carbon dioxide. maximum extent.
✓ HCO3 – the concentration of bicarbonate in arterial blood. 4. Total Lung Capacity – maximum volume to which the lungs can
✓ SaO2 – percentage of oxygen bound to Hgb as compared with be expanded with the greatest possible effort.
the total amount that can be possibly carried. • volume of air in the lungs at this level is equal to FRC (2300ml) in
ABGs can be obtained by an arterial puncture or through an arterial line. young adult.
Arterial Blood Sampling
• Technique is different from venous blood extraction. Promoting Oxygenation: Independent Nursing Actions
• Heparin is used to prevent blood clots. Positioning
• Blood is extracted from an artery. ✓ High Fowler’s
✓ Orthopneic
• No tourniquet is necessary.
Breathing Techniques
• Greater pressure is applied after the extraction (than with
✓ Deep breathing
venous) as more bleeding is expected.
✓ Pursed lip breathing
Arterial Blood Gases
✓ Diaphragmatic breathing
Specimen: arterial blood.
✓ Use of nasal strips
Pretest: obtain syringe with heparin, rubber stopper, container with ice.
Pursed Lip Breathing
Intratest: Collect arterial sample (usually radial artery is used).
• It is designed to make breaths slower and more intentional,
Post-test: Apply direct pressure on site for 5-10 minutes, send specimen
making them more effective.
with occluded needle on ice.
• Inhale by puckering the lips and exhale through them slowly and
deliberately, often to a count.

Normal Values for ABG Diaphragmatic Breathing

Parameter Arterial Blood • As air enters the lungs, the chest does not rise and the belly
pH 7.35 – 7.45 expands during this type of breathing
PaCO2 35-45 mmHg
PaO2 80-100 mmHg
HCO3- 22-26 mEq/L
Base excess/deficit +/- 2 mEq/L
Oxygen Saturation >94%
Blood pH levels below 7.35 reflect acidosis, and levels above 7.45 reflect
alkalosis.
Other tests
Pulse Oximetry – transcutaneous technique for assessing oxygen
saturation of the blood. Nasal Strips
Pulmonary Function Test – to determine lung volumes and capacities. • are made of flexible, spring-like bands that fit right above the flare
Pulmonary Volumes Pulmonary Capacities of the nostrils.
Tidal Volume – TV Inspiratory Capacity – IC • The underside is 3M adhesive so that once positioned on the
Inspiratory Research Volume – Functional Residual Capacity – nose, they stay there.
IRV FRC
• As the bands attempt to straighten back to their original shape,
Expiratory Reserve Volume – ERV Vital Capacity – VC
they lift the sides of the nose and open the nasal passages.
Residual Volume Total Lung Capacity – TLC
Note: Pulmonary Capacity = Lung volume + another lung volume.
Oxygen Therapy: A Medical Intervention
Pulmonary "Volumes”
Also known as supplemental oxygen, is the use of oxygen as a medical
1. Tidal Volume – volume of air inspired or expired with each
treatment for:
normal breath, about 500ml.
OUTLINE BY: CHARIS JILL A. DAUTIL
MEDICAL-SURGICAL NURSING 1
3rd Year | 1st Semester
Lecturer: Jim Rashid Hayudini, RN, MN

✓ low blood oxygen 3. Partial Rebreather mask – client inhales a mixture of

✓ carbon monoxide toxicity atmospheric air, oxygen from the source and oxygen contained
✓ cluster headaches within the reservoir bag (6-15L/min).
✓ Maintenance of enough oxygen while inhaled anesthetics are Provides high FIO2 since 1/3 of exhaled tidal volume is
given. rebreathed.
4. Non-rebreather mask – all exhaled air leaves the mask rather
than partially entering the reservoir bag.
It is designed to deliver fraction inspired oxygen by 90 – 100%.
5. Venturi mask – mixes a precise amount of oxygen and
atmospheric air.
Adapters within its tube allow specific amounts of room air to mix
with oxygen.
Delivers exact desired selected concentrations of O2.
Note: Since the jets in venturi masks generally limit oxygen flow to 12 to 15
liters per minute, the total flow decreases as the ratio decreases.
At an oxygen flow rate of 12 liters per minute and a 30% FiO2 setting, the
total flow would be 108 L/min.
Oxygen sources:
• Wall outlet: modern supply of O2.
• Portable tanks: can hold large volumes under strong pressure
(2,000Lbs/inch2).
• Liquid oxygen unit: converts cool liquid oxygen to gas by
passing through heat coils; safe to be used at home.
• Oxygen concentrator: collects and concentrates oxygen from
room air and stores it.
Equipment
• Flow meter – measures the flow of oxygen in liters per minute.
A gauge to regulate the amount of oxygen delivered.
6. Face tent – administer oxygen to nose and mouth without mask.
• Oxygen Analyzer – measures the percentage of delivered
It is open and loose around the whole face.
oxygen to determine whether the client is receiving the amount
Useful with facial trauma.
prescribed by the doctor.
Oxygen delivered is inconsistent.
Normal reading: 21% (room air)
7. Oxygen tent – used more for very
Near O2 source: >21%
young patient.
• Humidifier – produces small water droplets and may be used
Oxygen concentration is difficult to
during oxygen administration to prevent drying of mucus
control.
membrane.
Ensure that the edges of the tent
Uses distilled water (not saline, not tap water).
are tucked well.
Oxygen Therapy
8. Hyperbaric Oxygen (Hyperbaric
• When the oxygen saturation falls below 89 percent, or the
Oxygen Therapy HBOT) – it
arterial oxygen pressure falls below 60 mmHg — whether during
involves breathing pure oxygen in a
rest, activity, sleep or at altitude — then supplemental oxygen is
pressurized environment.
needed.
Useful procedure for different
• Long-term oxygen therapy (LTOT) - when oxygen is delivered infections, particularly in deep and
for patients with chronic hypoxemia, for at least 15 hours daily. chronic infections such as
Oxygen toxicity necrotizing fasciitis, osteomyelitis,
• lung damage that happens from breathing too much chronic soft tissue infections, and infective endocarditis.
(supplemental) oxygen. Terms
Also called oxygen poisoning. Asbestosis – diffuse lung fibrosis resulting from exposure to asbestos fiber.
• Can cause coughing and trouble breathing. Aspiration – entry of oropharyngeal or gastric content into lower airways.
• Severe cases are fatal. Consolidation – lung tissue that has become more solid in nature due to
collapse of alveoli or infection.
Empyema – accumulation of purulent material in the pleural space.
Pleural effusion – abnormal accumulation of fluid in pleural space (recall:
cardiac tamponade).
Restrictive lung disease – disease of the lung that causes a decrease in
lung volumes.
CONDITIONS OF THE UPPER RESPIRATORY
TRACT
Acute Pharyngitis
• Sudden, painful inflammation of the pharynx.
Oxygen Delivery Devices
• It includes the back of the throat, posterior tongue, soft palate,
1. Nasal cannula – for low concentration administration (1–6 L/min)
and tonsils.
Simplest, does not interfere with eating or talking.
2. Simple Face Mask – allows atmospheric air to enter and exit • Peaks during winter and cold seasons.
through side ports (5 – 8L/min). • Spreads fast via cough and droplet transmission.
Difficult for claustrophobic clients, interferes with eating and • Commonly viral: adenovirus, influenza, Epsteinn-Barr and HSV
talking. About 10% is bacterial (beta hemolytic Streptococcus)
• Strep throat – occurs from strep cause
OUTLINE BY: CHARIS JILL A. DAUTIL
MEDICAL-SURGICAL NURSING 1
3rd Year | 1st Semester
Lecturer: Jim Rashid Hayudini, RN, MN

Strep Throat Symptoms ✓ Exposure to sudden temperature change.

✓ Throat pain ✓ Dietary deficiencies and malnutrition.
✓ Fever ✓ Immuno-suppression
✓ Edema Manifestations
✓ Swelling in tonsil pillars, uvula and soft palate ✓ Hoarseness.
✓ Exudates may be present ✓ Aphonia.
✓ Lymph nodes may swell ✓ Severe dry cough.
Management ✓ Sore throat that worsens in the evening.
• Viral – symptomatic. ✓ Edematous uvula.
• Bacterial – antibiotics. ✓ Sense of “tickle” in the throat that worsens by cold air or liquids.
• Nutritional therapy. Management
• Warm gargles. • Voice rest.
• Health education. • Avoidance of irritants.
• Cool steam inhalation.
Chronic Pharyngitis • Medication like corticosteroids (beclomethasone).
• Persistent inflammation of the pharynx. • Proton Pump Inhibitor (PPI) for reflux laryngitis (GERD) like
3 types omeprazole.
1. Hypertrophic – general thickening and congestion of pharyngeal CONDITIONS OF THE LOWER RESPIRATORY
mucous membrane. TRACT
2. Atrophic – late stage of the first type, membrane is thin, whitish
Infectious Condition: Pulmonary Tuberculosis
and glistening.
• Is caused by various strains of mycobacteria, usually
3. Chronic granular – numerous swollen lymph follicles on
Mycobacterium tuberculosis.
pharyngeal wall
• Can also affect other parts of the body (TB of the bones, kidneys,
Manifestations
etc).
✓ Constant sense of irritation or fullness in the throat.
• Causes tubercles, fibrosis, and calcification within the lungs.
✓ Mucus collection in the throat.
✓ Dysphagia. Mode of Transmission – AIRBORNE
✓ Anorexia. Signs and Symptoms
✓ Intermittent postnasal drip. ✓ Tightness of chest
(dyspnea).
Management
✓ Unusual weight loss.
• Removal of irritants.
✓ Blood-tinged sputum.
• Treating other causes of cough.
✓ Exhaustion or fatigue.
• Short term use of nasal spray.
✓ Recurrent afternoon
• Antihistamine, decongestants, acetaminophen.
fever.
• Tonsillectomy for recurrent pharyngitis. ✓ Chronic cough.
✓ Low resistance to
Tonsillitis other infection.
• Infection of the tonsils that may involve the adenoids and pharynx ✓ Extensive weakness.
• Commonly caused by bacteria: GABHS (group A BHS). ✓ Sweats and chills especially a night.
• Viral: Epstein – Barr. Diagnostic Exam
• Common among children. • Radiology.
Manifestations • Tuberculin Skin Test – The Mantoux Method is preferred where
✓ Sore throat. 2 ”units” of tuberculin PPD RT23 is used.
✓ Fever. • Direct Sputum Smear Microscopy – microscopic examination
✓ Snoring. and microbiological culture of sputum.
✓ Dysphagia. • Sputum Examination
✓ With enlarged adenoids: mouth breathing, otitis, ear discharges, 1. Mouthwash with plain water.
bad breath, voice impairment. 2. Deeply inhale x 2 then cough.
Note: If left untreated may cause deafness. 3. Wear gloves.
Management 4. Collect 1-2 Tbsp or 15-30 ml.
• More fluids. Specimen collection
• Salt water gargles. • Patients presumed to have pulmonary TB disease may cough up
• Rest. sputum (phlegm) into a sterile container for processing and
• Analgesics. examination.
• Penicillin for bacterial infection. • Patients should have at least three consecutive sputum
• Tonsillectomy – if recurrent. specimens examined, each collected in 8 to 24-hour intervals (at
least one collected early in the morning).
Laryngitis • Specimens should be collected in an airborne infection isolation
• Inflammation of the larynx, often occurs as a result of voice abuse (AII) room, a sputum collection booth, or another isolated, well-
or exposure to dust, chemicals, smoke, other pollutants or as part ventilated area.
of URI • Other sputum specimen collection methods include inducing
• Is also associated with GERD. sputum, bronchoscopy, and gastric washing. Health care
• Common in the winter. providers should use precautions to control the spread of TB
Infection is usually associated with: bacteria during sputum collection procedures.
Allergic rhinitis, Pharyngitis In case the patient cannot cough out his sputum, use of suction may be
Usually associated with necessary for as long as the nurse observes proper techniques.

OUTLINE BY: CHARIS JILL A. DAUTIL

MEDICAL-SURGICAL NURSING 1
3rd Year | 1st Semester
Lecturer: Jim Rashid Hayudini, RN, MN

• an inflammatory condition of
the lung, especially of the
alveoli (microscopic air sacs in
the lungs).
• This disease is associated with
fever, chest symptoms, and
consolidation on a chest
radiograph.
• Pneumonia fills the lung's alveoli with fluid, hindering oxygenation.
Key Points • The alveolus on the left is normal, while on the right it is full of
• All persons with signs or symptoms of TB disease, or a positive fluid from pneumonia.
result from a TB blood test or TB skin test should be medically
evaluated for TB disease.
• A diagnosis of latent TB infection is made if the person has a
positive result from a TB blood test or TB skin test and a medical
evaluation does not indicate TB disease.
• TB disease is diagnosed by medical history, physical
examination, CXR, and other laboratory tests, including culture.
Categories of TB
Cases
1. New
Classification
2. Treatment Failure
1. Community – Acquired (CAP) – occurs in the community setting
3. Relapse
or within 48 hours after hospitalization or institutionalization.
4. Transfer – in
2. Health – Care Associated (HCAP) – causative pathogens are
5. Return after default
often MDR.
6. Other
Often difficult to treat.
3. Hospital – Acquired (HAP) – develops 48 hours or more after
admission and does not appear to be incubating at the time of
TB – DOTS Center – facility that is capable of delivering DOTS services admission.
(many health centers are DOTS centers). 4. Ventilator – Acquired (VAP) – subtype of HAP.
Management Occurs to patient who has been intubated and has received
Medication Therapy. mechanical ventilatory support for at least 48 hours.
RIPES – Rifampicin, Isoniazid, Pyrazinamide, Ethambutol, Streptomycin
Aspiration Pneumonia
• Pulmonary consequences resulting from entry of endogenous or
exogenous substances into the lower tract.
• Most common form is bacterial infection from aspiration of
bacteria that normally reside in the upper airways.
Causative Agents
• Bacteria are the most common cause of community acquired
pneumonia, with Streptococcus pneumoniae isolated in nearly
50% of cases.
• Virus – Rhinoviruses, Coronaviruses, Influenza virus.
Diagnostic Exams
Fixed-Dose Combination • Chest x – ray – consolidation.
• Two or more first-line anti-TB drugs are combined in one tablet. • Sputum smear and culture.
NOTE: Ordinary TB. • Blood exams.
• Treatment success of 90% with good DOTS program. • Others
• Treatment duration: 6 – 8 months. Management
• Treatment side effects: Mild to moderate (usually GI • Pharmacology (depends on the causative agent).
disturbances). Antibiotic, Antiviral, Analgesics and anti-inflammatory, and Others
Multi-Drug Resistant TB (MDRTB) • Isolation.
• Treatment success of about 80% with good MDR-TB programme • Aggressive respiratory management.
• Treatment duration: 18 – 24 months. • Hydration and nutritional therapy.
• Treatment side effects: severe to toxic (hearing loss, psychosis, • Influenza (Hib) vaccines and vaccines against Streptococcus
liver damage). Pneumoniae help prevent development of pneumonia among
Extensively Drug Resistant TB (XDR-TB) children and adults.
• Treatment success of less than 50%; usually incurable
• Treatment duration: exceeds 2 years. Pulmonary Embolism and Infarction
• Treatment side effects: severe to toxic (hearing loss, psychosis, Thrombus in peripheral circulation detaches (ex.DVT) -> Embolus travels
liver damage). thru the heart then lodges in the pulmonary artery -> Hemorrhage and
necrosis of lung tissues -> Pulmonary tissue infarction.
Pneumonia

OUTLINE BY: CHARIS JILL A. DAUTIL

MEDICAL-SURGICAL NURSING 1
3rd Year | 1st Semester
Lecturer: Jim Rashid Hayudini, RN, MN

Clinical Findings
✓ Severe, sudden
dyspnea.
✓ Anxiety.
✓ Restlessness.
✓ Sharp pleuritic
pain. CoViD – 19
✓ Increased • The World Health Organization declared the COVID-19 outbreak
temperature. a public health emergency of international concern (PHEIC) on 30
✓ Increased pulse. January 2020 and a pandemic on 11 March 2020.
✓ Increased • An infectious disease caused by severe acute respiratory
respiratory rate. syndrome coronavirus 2 (Mayo Clinic, 2020).
✓ Violent coughing. • First identified in December 2019 in Wuhan, Hubei, China, and
✓ Hemoptysis. has resulted in an ongoing pandemic (WHO, 2019).
✓ Diaphoresis • First confirmed case has been traced back to 17 November 2019
Medical-Surgical Management in Hubei.
• Anticoagulant therapy. Transmission: droplet
• Thrombolytic therapy. • Incubation period: 5 – 14 days.
• Angiography – embolectomy is done in severe cases. Most contagious during the first three days after the onset of
• Vena cava interruption – a filter may be implanted in the inferior symptoms (some patients are asymptomatic).
vena cava preventing the passage of large thrombi. • No cure at present.
Nursing Management Vaccines are available but do not provide 100% immunity (Herd
• Place in High Fowler’s position. immunity is the main goal).
• Administer oxygen. • Treatment is symptomatic; antivirals are given for severe cases.
• Monitor for hypoxemia and right – sided heart failure. • There is tentative evidence for efficacy by remdesivir, and on 1
• Administer medications as prescribed. May 2020, the United States Food and Drug Administration (FDA)
• Maintain calm environment. gave the drug an emergency use authorization for people
hospitalized with severe COVID-19.
• Provide health teachings.
Manifestations
Postural Drainage
✓ Fever.
• is a procedure that involves the drainage of lung secretions using
✓ Cough.
gravity.
✓ Fatigue.
• is used to treat a variety of conditions that cause the build-up of
✓ Shortness of breath/ dyspnea.
secretions in the lungs.
✓ Anosmia.
• Depending on the anatomical angle of the lobes or segments of ✓ Loss of taste sensation.
the lungs to be drained, the patient may be placed in sitting, ✓ Diarrhea.
prone, supine, side lying or in a head down tilt of between 15 and ✓ Other flu-like symptoms (myalgia, arthralgia).
30 degrees.
CoViD – 19 Complications
• The person lies or sits in various positions so the part of the lung ✓ Acute Respiratory Distress Syndrome (ARDS) possibly
to be drained is as high as possible. precipitated by cytokine storm.
• That part of the lung is then drained using percussion, vibration ✓ Multi-organ failure.
and gravity. ✓ Septic shock.
✓ Thromboembolism
Diagnostic Tests
• Real-time Reverse Transcription Polymerase Chain Reaction
(rRT-PCR) from a nasopharyngeal swab.
CoViD – 19 Variants
As of July 2021, there are four dominant variants of SARS-CoV-2 spreading
among global populations:
1. Alpha Variant (formerly called the UK Variant and officially referred to as
B.1.1.7), first found in London and Kent
2. Beta Variant (formerly called the South Africa Variant and officially
referred to as B.1.351)
3. Gamma Variant (formerly called the Brazil Variant and officially referred to
as P.1)

OUTLINE BY: CHARIS JILL A. DAUTIL

MEDICAL-SURGICAL NURSING 1
3rd Year | 1st Semester
Lecturer: Jim Rashid Hayudini, RN, MN

4. Delta Variant (formerly called the India Variant and officially referred to as • Maintain patent airway – suction PRN.
B.1.617.2. • Administer medications as prescribed.
Resuscitation for CoViD-19 • Maintain calm environment.
Patients American Heart Association, 2020 • Provide health teachings.
• Don personal protective equipment (PPE) according to local
guidelines and availability before beginning CPR. Asthma
• Minimize the number of clinicians performing resuscitation; use a • reversible bronchospasms and increased secretions that lasts
negative-pressure room whenever possible; keep the door to the minutes to several hours.
resuscitation room closed if possible. • Obstruction of the bronchioles is characterized by attacks that
• May use a mechanical device, if resources and expertise are occur suddenly and last from 30 – 60 minutes.
available, to perform chest compressions on adults and on • An asthmatic attack that is difficult to control is called STATUS
adolescents who meet minimum height and weight requirements. ASTHMATICUS
• Use a high-efficiency particulate air (HEPA) filter for bag-mask Pathophysiology
ventilation (BMV) and mechanical ventilation. The underlying pathophysiology in asthma is reversible and diffuse airway
Negative Pressure Facility inflammation that leads to airway narrowing.
1. Activation. When the mast cells are activated, it releases several
chemicals called mediators.
2. Perpetuation. These chemicals perpetuate the inflammatory
response, causing increased blood flow, vasoconstriction,, fluid
leak from the vasculature, the attraction of white blood cells to the
area, and bronchoconstriction.
3. Bronchoconstriction. Acute bronchoconstriction due to
allergens results from a release of mediators from mast cells that
directly contract the airway.
4. Progression. As asthma becomes more persistent, the
Pulmonary Edema inflammation progresses and other factors may be involved in the
• An acute emergency condition characterized by a rapid airflow limitation.
accumulation of fluid in the alveolar spaces resulting from Causes
increased pressure within the pulmonary system. • Allergy.
Possible Causes Allergy is the strongest predisposing factor for asthma.
✓ Valvular disease • Chronic exposure to airway irritants.
✓ Left ventricular failure Irritants can be seasonal (grass, tree, and weed pollens) or
✓ Circulatory overload perennial (mold, dust, roaches, animal dander).
✓ Aspiration of gastric contents • Exercise.
✓ Drowning Too much exercise can also cause asthma.
Clinical Findings • Stress/ Emotional upset.
Subjective cues This can trigger constriction of the airway leading to asthma.
✓ Premonitory symptoms: shortness of breath. • Medications.
✓ Paroxysmal nocturnal dyspnea. Certain medications can trigger asthma.
✓ Wheezing. Clinical Manifestations
✓ Orthopnea. ✓ Cough (with or without mucus production)
✓ Acute anxiety. ✓ Dyspnea.
✓ Apprehension and restlessness General tightness may occur which leads to dyspnea.
Objective cues ✓ Wheezing. There may be wheezing, first on expiration, and then
✓ Rapid, thready pulse. possibly during inspiration as well.
✓ Rapid respiration. ✓ Asthma attacks frequently occur at night or in the early morning.
✓ Pink frothy sputum. ➢ An asthma exacerbation is frequently preceded by increasing
✓ Wheezing. symptoms over days, but it may begin abruptly.
✓ Crackles. ✓ Expiration requires effort and becomes prolonged.
✓ Pallor or cyanosis. ✓ As exacerbation progresses, central cyanosis secondary to
✓ Low PO2. severe hypoxia may occur.
✓ Elevated pulmonary capillary wedge pressure (PCWP) and ✓ Additional symptoms, such as diaphoresis, tachycardia, and a
central venous pressure (CVP). widened pulse pressure, may occur.
Medical – Surgical Management Treatment
Medications that will decrease cardiac workload and improve cardiac • Avoidance of allergen.
output: • Rest, positioning.
✓ Morphine Sulfate.
• Hydration.
✓ Digitalis.
• Nutritional support.
✓ Diuretics.
Medications: Bronchodilators, Antihistamine, Oxygen
✓ Vasodilators.
✓ Bronchodilators.
Chronic Obstructive Pulmonary Disease
✓ High Concentrated O2 or by PEEP.
• a group of diseases that results
✓ Hemodynamic monitoring.
in chronic airflow limitation
Nursing Management
(CAL); also called Chronic
• Place in Orthopneic, High Fowler’s or semi-Fowler’s position with
Obstructive Lung Disease
legs dependent.
(COLD)
• Monitor VS, cardiac activity and I & O.
Possible etiologies include
OUTLINE BY: CHARIS JILL A. DAUTIL
MEDICAL-SURGICAL NURSING 1
3rd Year | 1st Semester
Lecturer: Jim Rashid Hayudini, RN, MN

• Pollution – particularly air pollution. • Bronchodilators.

• Allergic reactions • Mucolytics and expectorants.
• Chronic respiratory infection • Oxygen at 1 – 2 Liters even if hypoxia is severe.
• Exposure to molds and fungi • Respiratory therapy program: nebulizer therapy, postural
• Smoking drainage, exercise.
COPD May precipitate • High CHON soft diet, small but frequent feedings.
• pulmonary hypertension, cor pulmonale, right ventricular heart
failure
COPD – Types
1. Chronic Bronchitis – inflammation of the bronchial walls with
hypertrophy of the mucous goblet cells.
Characterized by chronic cough.
2. Emphysema – characterized by distended, inelastic or destroyed
alveoli with bronchiolar obstruction and collapse.
Alterations greatly impair the diffusion of gases through the
alveolar capillary membrane.
3. Bronchiectasis – chronic dilatation of the bronchi and
bronchioles as a result of infection or obstruction.
Results to loss of elasticity. Main difference between COPD and Asthma
➢ Clients with COPD become accustomed to an elevated residual • One main difference is that asthma typically causes attacks of
carbon dioxide level. wheezing and tightness in the chest.
➢ They do not respond to high CO2 concentrations as the normal • COPD symptoms are usually more constant and can include a
respiratory stimulant. cough that brings up phlegm.
➢ They respond instead to a drop in oxygen concentration in the
blood
Clinical Findings
✓ Fatigue.
✓ Weakness.
✓ Dyspnea.
✓ Headache.
✓ Impaired sensorium.
✓ Orthopnea, expiratory wheezing, abnormal breathing sounds,
cough.
✓ Distended neck veins, peripheral edema (right heart failure).
✓ Barrel chest, cyanosis, clubbing of fingers, use of accessory
muscles, pursed lip breathing.
Barrel Chest Pneumothorax
• a rounded, bulging chest that is similar in • Collapse of the lung resulting from
shape to a barrel. disruption of the negative pressure
that normally exists within the intra
• While not technically a medical term, the
pleural space
term "barrel chest" is often used by
healthcare providers to describe a • Caused by the presence of air in the
physical characteristic consistent with pleural cavity; may be associated with
cases of late-stage emphysema, in which fractured ribs
the chest may become fixed in an • Reduces the surface area for
outward position. gaseous exchange and leads to
• Barrel chest can also occur with cystic hypoxia and retention of carbon dioxide.
fibrosis, severe asthma, and other health issues. Types: Spontaneous, Open, Hemothorax, Hydrothorax, Tension
Pigeon Chest 1. Spontaneous (closed)
• Pectus carinatum is a rare chest wall • Thought to occur when a weakened area of the lung (bleb)
deformity that causes the breastbone to ruptures.
push outward instead of being flush • Air then moves from the lung to the intra pleural space causing
against the chest. collapse.
• It is also known as pigeon chest or keel • Highest incidence in men (20 – 40 years old).
chest. 2. Open.
• When the chest wall develops, the • Occurs with laceration through the chest wall into the intra pleural
cartilage that connects the ribs usually space.
grows flat along the chest. • Occurs with stab wound and similar injuries.
• In cases of pectus carinatum, this 3. Hemothorax.
cartilage grows abnormally, causing unequal growth in the areas • Collection of blood within the pleural cavity.
where the ribs connect to the sternum. This causes the outward 4. Hydrothorax.
appearance of the chest wall. • Accumulation of fluid in the pleural cavity
Laboratory Findings 5. Tension Pneumothorax.
Increased PCO2 , Decreased PO2, Polycythemia • Build up of pressure as air accumulates within the pleural space.
Management • The pressure increase is likely to induce a mediastinal shift.
• Steroids – to reduce inflammation.
• Antibiotics – prevent or treat infection. Mediastinal shift

OUTLINE BY: CHARIS JILL A. DAUTIL

MEDICAL-SURGICAL NURSING 1
3rd Year | 1st Semester
Lecturer: Jim Rashid Hayudini, RN, MN

• May occur toward the uninvolved side as a result of increased • The suction control chamber is the chamber on the left side of the
pressure within the pleural space; this involves the trachea, unit. The units come with two mechanisms to regulate the amount
esophagus, heart and great vessels of suction transmitted to the pleural space: wet or dry suction. Wet
Flail chest suction regulates the amount of suction by the height of a column
• Instability of chest wall related to fractures of the ribs or detached of water in the suction control chamber.
sternum; • A suction pressure of –20 cm H2O is commonly
• Caused by crashing chest injuries recommended For Adults.
Atelectasis Chest Tube Care
• Occurs with collapse of one or more areas in a lung 1. Promote drainage.
Subjective Cues Ensure the chest tube remains free from kinks and occlusions. Keep the
✓ Chest pain – sharp and increasing on exertion. drainage system below the level of the patient’s chest. Do not let the
✓ Dyspnea. drainage system tip over, as water can contaminate other chambers.
✓ Drowsiness 2. Assess drainage.
Objective Cues Assess drainage in the collection chamber and document the
✓ Tachycardia. color, characteristics, and amount per facility guidelines. Mark the
✓ Hypotension. drainage level with the time and date to reference during the shift.
✓ Rapid and shallow respirations. 3. Assess for tidaling.
✓ Diminished or absent breath sounds on the affected side. Tidaling is the rise and fall of water in the water-seal chamber that
✓ With flail chest: loose segments move inward with correlates to inhalation and exhalation and ensures the chest tube
inspiration and outward with expiration is patent.
Management 4. Monitor the insertion site.
• Bed rest. Assess for signs of infection, such as redness, bleeding, or
• Analgesics and antibiotics. purulent drainage. Palpate the area for crepitus, which can
indicate subcutaneous emphysema (when air leaks into the
• Chest tube insertion to water – sealed drainage system.
subcutaneous tissues).
• Restoration of blood volume.
5. Collaborate with the respiratory therapist.
• Volume controlled ventilation.
Collaborate with the respiratory therapist about the care plan for
What is a Chest Tube?
chest tube insertion and monitoring. If you are unsure about
• A chest tube goes by many different names, including chest abnormalities in the drainage system or chest tube, ask the
drainage tube and chest drain. respiratory therapist for help.
• The plastic tube enters the side of the patient’s chest to remove 6. Prevent chest tube complications.
blood, air, or fluid from around the heart and lungs. Chest tubes can result in the following complications,
• The lung contains two tissue layers called pleura that contain fluid including:
that assists the lungs with helping patients breathe. ✓ Bleeding.
• Conditions and diseases—such as pleural effusion, emphysema, ✓ Infection.
tumors, heart failure, hemothorax, infection, and pneumothorax— ✓ Deep organ space infection (empyema).
may cause blood, air, or additional fluid to gather in the pleural ✓ Tube dislodgement.
space. ✓ Clogs in the tube.
• The chest tube helps the patient breath better by expanding the ✓ Re-expansion pulmonary edema.
lungs. Without the use of a chest tube, patients who have certain ✓ Intraabdominal organ injury.
conditions and diseases may have their lungs collapse if the 7. Promote drainage and lung expansion.
pressure becomes too great in their chest. Continue to assist the patient in repositioning, ambulation,
Chest Tube Water-sealed Drainage System coughing, and deep breathing techniques to promote fluid
• The collection chamber is at the right side of the unit. The 6-foot drainage and lung re-expansion.
tubing connects directly to the chest tube. Chest Tube Complications
• Any fluid drainage from the chest goes into this chamber. It is 1. Continuous or intermittent bubbling means an air leak.
usually calibrated in 1 ml increments up to 100 ml, 2 ml If continuous or intermittent bubbling is observed in the water-seal
increments from 100 ml to 200 ml and 5 ml increments from 200 chamber, this indicates an air leak. To assess the location of the
ml to 2500 ml. It has a surface that can be marked with the time leak, clamp the tubing along the tube to evaluate for a leak at the
and date of drainage. chest wall, the tube, or the drainage system.
• The water seal chamber is the middle chamber. When this 2. Dislodgement is an emergency.
chamber is filled with fluid up to the 2 cm line, a 2 cm water seal is It is an emergency if the tube becomes dislodged from the patient.
established. Immediately cover the insertion site with a sterile occlusive
• A short latex tube at the top of this chamber is either left open to dressing and alert the provider so a tube can be reinserted.
air for gravity drainage or attached to a suction source. 3. Bleeding.
• The water seal chamber should have fluid gently bubbling ASSESS. Bleeding is normal after insertion, but if a large amount
immediately upon insertion of the chest tube, during expiration of bright red bleeding is observed in the collection chamber, this
and with coughing. can indicate hemorrhage.
• The original purpose of the water seal – keeping air from entering 4. No drainage could mean clogging.
the pleural cavity. If no drainage occurs within the first 24 hours of insertion, the tube
• The water level in the water seal should be monitored routinely to may be clogged (unless the chest tube is only draining air). First,
check for evaporation. inspect for kinks, reposition the patient, and assess the drainage
system. If unsuccessful, contact the provider.
• Continuous bubbling in this chamber indicates a leak in the
5. Get a new drainage system if it breaks.
system.
If the drainage system becomes cracked or broken, obtain a new
• Fluctuations in the water level in the water-seal chamber of 5 to
one. In the meantime, insert the tubing 1” into a bottle of sterile
10 cm, rising (during inhalation) and falling (during expiration),
water to create a water seal.
should be observed with spontaneous respirations.

OUTLINE BY: CHARIS JILL A. DAUTIL

MEDICAL-SURGICAL NURSING 1
3rd Year | 1st Semester
Lecturer: Jim Rashid Hayudini, RN, MN

6. Do not milk, clamp, or strip the tubing.

Unless directed by the physician, do not milk, strip, or clamp
(unless assessing for an air leak) the tubing, as this could cause a
tension pneumothorax.

Acute Respiratory Distress Syndrome

Respiratory failure as a complication of
✓ Trauma.
✓ Aspiration.
✓ Prolonged mechanical ventilation.
✓ Severe infection.
✓ Open-heart surgery.
✓ Fat emboli.
✓ Shock, etc.
ARDS involves the following:
• Pulmonary capillary damage with loss of fluid and interstitial
edema.
• Impaired alveolar gas exchange and tissue hypoxia resulting from
pulmonary edema.
• Alteration in surfactant production; collapse of alveoli.
• Atelectasis resulting in labored and inefficient respiration
Subjective Cues: Restlessness, Anxiety, Dyspnea
Objective Cues
✓ Tachycardia.
✓ Grunting respirations.
✓ Intercostal retractions.
✓ Cyanosis.
✓ PCO2 – increased initially and later decreased.
✓ Decreased PO2.
✓ Pulmonary edema.
Management
• Mechanical ventilation with PEEP to maintain positive pressure
within the lungs at the end of expiration, which increases the
residual capacity, reducing hypoxia.
• Corticosteroids.
• Relieve underlying cause
Thoracentesis
• a procedure that is performed to remove fluid from the thoracic
cavity. This can be done for both diagnostic and therapeutic
purposes.
• A potential space exists in the left and right side of the chest
cavity between the inner chest wall and lung.

Special Feature: Lung Transplant

• or pulmonary transplantation, is a surgical procedure in which a
patient's diseased lungs are partially or totally replaced by lungs
which come from a donor.
• Donor lungs can be retrieved from a living donor or a deceased
donor. A living donor can only donate one lung lobe.

OUTLINE BY: CHARIS JILL A. DAUTIL